Health and non-health benefits and equity impacts of individual-level economic relief programs: A Scoping Review
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A preprint titled Health and non-health benefits and equity impacts of individual-level economic relief programs during epidemics/pandemics in high income settings: A Scoping Review, by Adeteju Ogunbameru and colleagues at the University of Toronto, York University, University Health Network and other institutions. The cover page lists the keywords pandemic preparedness, epidemics, COVID-19, infectious disease and equity, and gives a posted date of October 12th, 2023. It states that the work is licensed under a Creative Commons Attribution 4.0 International License and that a version was published at BMC Public Health on August 5th, 2024.
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“Health and non-health benefits and equity impacts of individual-level economic relief programs: A Scoping Review.”
Original at doi.org. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/health-and-non-health-benefits-and-equity-impacts-of-individual-level-economic-relief-programs-during-epidemics-pandemic/
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Health and non-health benefits and equity impacts of individual-level
economic relief programs during epidemics/pandemics in high income
settings: A Scoping Review
Adeteju Ogunbameru
University of Toronto
Gebremedhin BeedMariam Gebretekle
University of Toronto
Adrianna Perryman
York University – Keele Campus
Marian Hassan
University Health Network
Ashley Farrell
University Health Network
Kaun Liu
University of Toronto
Sharmistha Mishra
Centre of Urban Health Solutions, Michael’s Hospital
Beate Sander
University Health Network
Research Article
Keywords: pandemic preparedness, epidemics, COVID-19, Infectious disease, equity
Posted Date: October 12th, 2023
DOI: https://doi.org/10.21203/rs.3.rs-3408285/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License
Additional Declarations: No competing interests reported.
Version of Record: A version of this preprint was published at BMC Public Health on August 5th, 2024. See the published version at
https://doi.org/10.1186/s12889-024-19493-8.
Page 1/20
Abstract
Background
Economic relief programs are strategies designed to sustain societal welfare and population health during a regional or global scale infectious disease
outbreak. While economic relief programmes are considered essential during a regional or global health crisis, there is no clear consensus in the literature
about their health and non-health benefits and their impact on promoting equity.
Methods
We conducted a scoping review, searching eight electronic databases from January 01, 2001, to April 3, 2023, using text words and subject headings for
recent pathogens (coronavirus (COVID-19), Ebola, Influenza, Middle East Respiratory Syndrome (MERS), severe acute respiratory syndrome (SARS), HIV, West
Nile, and Zika), and economic relief programs; but restricted eligibility to high-income countries and selected diseases due to volume. Title and abstract
screening were conducted by trained reviewers and Distiller AI software. Data were extracted in duplicates by two trained reviewers using a pretested form,
and key findings were charted using a narrative approach.
Results
We identified 27,263 de-duplicated records, of which 50 were eligible. Included studies were on COVID-19 and Influenza, published between 2014 and 2023.
Zero eligible studies were on MERS, SARS, Zika, Ebola, or West Nile Virus. We identified seven program types of which cash transfer (n = 12) and vaccination
or testing incentive (n = 9) were most common. Individual-level economic relief programs were reported to have varying degrees of impact on public health
measures, and sometimes affected population health outcomes. Expanding paid sick leave programs had the highest number of studies reporting health-
related outcomes and positively impacted public health measures (isolation, vaccination uptake) and health outcomes (case counts and the utilization of
healthcare services). Equity impact was most often reported for cash transfer programs and incentive for vaccination programs. Positive effects on general
well-being and non-health outcomes included improved mental well-being and quality of life, food security, financial resilience, and job security.
Conclusions
Our findings suggest that individual-level economic relief programs can have significant impacts on public health measures, population health outcomes and
equity. As countries prepare for future pandemics, our findings provide evidence to stakeholders to recognize health equity as a fundamental public health
goal when designing pandemic preparedness policies.
BACKGROUND
Infectious disease epidemics and pandemics can result in catastrophic economic collapse and disastrous human, social, and health consequences (1).
Populations experiencing social and economic marginalization have consistently experienced the highest risk of infection, disease severity and death (2–4).
Across high-income settings, racially minoritized individuals experienced disproportionate burden of COVID-19, H1N1 influenza, and tuberculosis (3, 5, 6);
driven by how systemic racism has shaped occupational risks, housing, and health care (6).
Individual-level economic relief programs are economic interventions implemented by governments, institutions, or private sources during an epidemic or
pandemic to limit the disproportional health and economic consequences often experienced by populations at higher risk of the disease (e.g., low- and
modest-income families, families with children, homeless population, and indigenous persons), support public measures and improve population health (7).
Programs implemented during the COVID-19 pandemic included paid sick leave, caregiver and childcare benefits, unemployment compensations for
furloughed workers, and food supply and direct cash payments to low-income earners (7).
Pandemic-informed individual level economic relief policies are intended to encourage changes in human behaviour and motivate individuals to make healthy
choices that impact health and overall well-being; (8) however, we found very limited evidence on the health-related benefits of individual level economic
relief programs in our exploratory review, conducted in few electronic databases in September 2020 to assess the feasibility of a broader review.
Because the implementation individual level economic relief programs are often costly (7) and there is often a debate about their impact during outbreaks
(9), we systematically chart their health and non-health benefits, and equity impacts to inform pandemic preparedness planning.
Our objective is to map the current state of the literature on individual-level economic relief programs during infectious disease outbreaks and their impact on
the effectiveness of public health measures, individual and population health, non-health outcomes, and health equity during regional or global scale
infectious disease outbreaks. Our review questions are:
1. What are the types of individual-level economic relief programs implemented during an infectious disease outbreak?
2. How and to what extent do pandemic/epidemic individual-level economic relief programs impact the effectiveness of public health measures during
epidemics?
3. How and to what extent do changes in public health measures associated with pandemic/epidemic individual-level economic relief programs impact
health outcomes?
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4. Do health benefits associated with pandemic/epidemic individual-level economic relief programs differ across demographic and social groups, and
place of residence? If so, how?
5. What are the non-health outcomes assessed in eligible studies identified?
6. What are the limitations associated with pandemic/epidemic individual-level economic relief programs?
7. What are the knowledge gaps in the literature in relation to the questions above?
METHODS
We followed the updated Arksey and O’Malley’s framework on conducting scoping review (10, 11) and the Preferred Reporting Items in Systematic Reviews
and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guideline (12).
Our protocol is available at doi: 10.1136/bmjopen-2021-057386. (13)
Search strategy
An information specialist developed our comprehensive search strategy using text words and Medical Subject Headings (MeSH) terms. In the original search
strategy, from January 1, 2001, to October 8, 2021, we searched concepts relating to pandemic/epidemic infectious diseases (specifically, coronaviruses,
influenza A, SARS, MERS, HIV/AIDS, Zika, Ebola and West Nile) and economic relief programs (e.g., government financing, public assistance, food assistance,
medical assistance, workers compensation, social welfare, charities, and childcare). We restricted our search to 2001 onwards because of the differences in
living standard and public health systems over time. We updated our search on April 3, 2023. For the updated search, we excluded HIV terms from the search
strategy due to the volume of HIV/AIDS publications during the original screening =. The original search strategy was developed in the Ovid Medline and then
translated to other databases. Both MEDLINE search strategies are reported in the appendix.
We searched eight databases - MEDLINE, OVID E-pub Ahead of Print In-Process & Other Non-Indexed Citations, EMBASE, Cochrane CENTRAL, all on the
OvidSP platform; EconLit, CINAHL, on the EBSCO platform; ISI Web of Science on the Clarivate platform, and Global Index Medicus from the World Health
Organization (WHO). We manually searched the reference lists of eligible studies to ensure we do not miss relevant articles.
Our search excluded clinical conferences, comments, editorials, letters, and animal studies. No study design, language or country restriction was employed in
our search strategy.
Study screening and Data extraction
De-duplication, and title and abstract screening were conducted using the Distiller SR software, including the artificial intelligence (AI) simulation tool that
automates the title and abstract screening process (14). Four trained reviewers conducted the title and abstract screening in parallel without using Distiller
AI. Distiller AI was used at the end of the screening process to check for screening errors among excluded records. Retrieved records were tagged by country
type (high-income or low-and-middle-income) and disease (HIV, COVID-19, Zika, Ebola, West Nile, MERS, SARS, or influenza A (H1N1 and H2N2). We excluded
commentaries, book chapters, conference abstracts with no full text, study protocols, and business targeted economic relief programs.
Following title and abstract screening, we restricted study eligibility to COVID-19, Zika, Ebola, West Nile, MERS, SARS, or influenza A (H1N1 and H2N2) and
high-income settings due to volume (see Fig. 1 for details on the excluded studies). We also excluded non-English articles due to limited translation
resources.
Full text screening and data extraction were conducted in duplicates by two trained reviewers using Microsoft Excel software. Disagreements were resolved
through discussions until consensus was reached. Data abstraction was conducted using a pre-tested template. Data elements included study and
population characteristics (study objective, study design, study population), infectious disease outbreak description (name of outbreak and time of outbreak),
economic relief program description (eligible population, program and equity considerations used in assessing eligibility and program implementation time
period), public health measure outcomes, population health outcomes, general health outcomes, equity impacts (by variables such as demographics, social
and jurisdiction), and non-health outcomes. Data extraction and synthesis on equity impact was guided by the PROGRESS-Plus framework to ensure we
systematically consider health equity under relevant dimensions, including demography, social factors, disability, and sexual orientation (15). Individual level
economic relief programs were categorized by the nature of the program and intended population. For examples, monetary incentive programs directed to
increase vaccine uptake or testing were categorized as “incentive for vaccination or testing” program; fiscal stimulus directed to workers when ill/exposed to
encourage quarantine/isolation was termed “expanded paid sick leave”; employment insurance payment to furloughed workers or unemployed individuals
was termed “unemployed assistance”; direct cash payment to support individuals and households was termed “cash transfer” food supply programs to
communities, schools, households was categorized as “food assistance”; two or more individual-level economic relief program groups simultaneously was
termed “mixed program” and “others” program category which included subsidy program and expanded child tax credit program.
Full details of the data elements extracted is described in our protocol (13).
Data charting
We summarized public health measures, health, non-health measures and equity impact associated with individual-level economic programs using a
narrative approach and visual plots. In the equity-impact analysis, we provided details on how outcomes differed by equity variables.
RESULTS
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Our initial and updated search yielded 27,263 de-duplicated records from the eight databases. After title and abstract screening, we retrieved 415 records for
full-text screening. Following the amended eligibility criteria, we excluded 227 studies from low- and middle-income countries and 45 studies on HIV from
high-income countries. We assessed the full text of 143 studies and excluded 93 records. The reasons for exclusions included: no quantitative assessment
of the individual-level economic relief program (n = 33), not an individual-level economic relief program (n = 23), and book/commentary/report/opinion/
research letters/conference abstract/media release (n = 25). Fifty studies were found eligible for final review. The PRISMA flow diagram is shown in Fig. 1.
Insert Fig. 1
Studies and Program characteristics
Eligible studies were published between 2014 and 2023. Ninety percent (90%) were COVID-19 related (n = 45) and others were on influenza (n = 5). We did not
identify eligible studies on MERS, SARS, Zika, Ebola, or West Nile virus. Seventy-three percent of included studies were conducted in the United States of
America (n = 36) (16–50), followed by Japan (51–53), South Korea (43, 54, 55), Australia (56, 57), Canada (58, 59), Chile, Israel, Spain, and Singapore (60–63).
Two-third of eligible studies used a survey study design (17, 19, 22, 28, 29, 32–34, 36, 38, 43–47, 50–54, 57, 59, 61, 63–67); others included quasi-experiment
(25, 41), simulation (20, 22, 27, 55, 60, 69), observational (26, 38, 49, 56), and randomized control trial design (42, 48, 58, 62).
We identified 28 unique individual-level economic relief programs among eligible studies and categorized them into seven groups.
Of the 50 eligible studies, three sets of seven studies reported on COVID-19 related unemployment assistance programs (18, 19, 22, 23, 26, 30, 47), COVID-19
food assistance programs (22, 24, 28, 40, 43, 44, 46), and expanded paid sick leave (16, 25, 34–36, 39, 49) in the context of COVID-19 pandemic and Influenza
epidemic. Eleven eligible studies reported on COVID-19 cash transfer programs (17, 20, 45, 48, 50, 52, 54, 56, 58, 68, 69); nine studies evaluated vaccine and
testing incentives during COVID-19 pandemic and Influenza epidemic (29, 33, 37, 38, 42, 55, 57, 62, 63); seven assessed mixed programs (27, 31, 32, 51, 59–
61), three of which combined unemployment assistance and cash transfer programs (27, 31, 59). Two COVID-19 studies reported on programs in the “other
“category (41, 53).
Figure 2 presents the program and study characteristics as a heat map.
Insert Fig. 2
Health, non-health, and equity outcomes of individual-level economic relief programs
All eligible studies reported on at least one review outcome. Studies on expanding paid sick leave programs reported the most health-related outcomes (n =
7) (16, 25, 34–36, 39, 49). The impact on non-health outcomes was commonly assessed for cash transfer programs (n = 10) (17, 20, 48, 50, 52, 54, 56, 58, 68,
69). Incentive for vaccination program studies contributed majorly to the equity data (n = 3) (29, 42, 62).
Figure 3 presents a Coxcomb chart of study outcomes by individual-level economic relief program type.
Insert Fig. 3
Health impacts
Thirty-six of the 50 eligible studies were designed to evaluate the health impact of an economic relief program (16–18, 25, 29, 32–42, 45, 49, 51, 53–55, 57,
58, 62, 63).
Impact on public health measures. Fifteen out of 50 studies were designed to examine the effect of economic relief programs on public health measures (25,
29, 33, 34, 36–39, 42, 53, 57, 58, 62, 63, 68).
Three studies, reporting on programs of expanded paid sick leave (n = 1), domestic travel subsidy (n = 1), and cash transfer (n = 1), found that economic relief
programs could have a positive, neutral, or negative impact on social distancing, depending on program type (39, 53, 58). Two studies reported that expanded
paid sick leave increased the probability of workers isolating when sick by 15% (25) and increased the time spent away from work when sick by 1.10 days
(35). Expanding paid sick leave significantly increased vaccination coverage during influenza disease outbreaks by 10–15% (34, 36). Vaccine incentives were
reported to significantly increase vaccination rates by 7% − 23.2% (29, 37, 62) in the context of COVID-19 and influenza outbreaks. A domestic travel subsidy
program had no impact on masking practice, respiratory hygiene practice & surface disinfection (53).
Population health outcomes based on programs’ impact on public health measures were evaluated by eight studies (29, 36, 38, 39, 53, 55, 58). Health
outcomes reported on included symptom and case counts, infection transmission, healthcare visits and herd immunity. The economic relief programs were
cash transfers (58), expanded paid sick leave (16, 35, 36, 39), incentives for vaccination/testing (29, 55), and domestic travel subsidy (53). Expanded paid
sick leave and incentive for vaccination/testing were associated with positive health outcomes (16, 29, 35, 36, 39, 55) while cash transfer and domestic travel
subsidy were linked to neutral (58) and negative health outcomes (53) respectively.
General well-being outcomes were reported in thirteen studies (17, 18, 32, 34, 36, 41, 43, 45, 49, 51, 58, 63, 67). The economic relief program types assessed
included cash transfer (n = 4), unemployment assistance (n = 1), paid sick leave (n = 1), food assistance program (n = 2) and expanded child tax credit (n = 1).
Cash transfer, unemployment assistance, food assistance, and expanded child tax credit were reported to have a positive impact on mental well-being in
seven studies (17, 18, 32, 41, 43, 45, 67). Paid sick leave was associated with intention to seek medical care; food assistance programs were associated with
healthier eating and improved intention to seek medical care when ill (34, 67).
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Non-health impacts
Thirty-three of the 50 (60%) eligible studies reported non-health outcomes (17–20, 22, 23, 26, 28, 31, 36, 38, 52, 54, 58–61, 65–66, 69, 72). Economic relief
programs had a positive impact on non-health measures including food security, financial resilience/savings/financial security, consumption spending and
debt payment, housing/mortgage payment and job security. Programs included cash transfer (n = 10), unemployment assistance (n = 10), incentive for
vaccination (n = 1), food assistance (n = 6), mixed (n = 4) and expanded paid sick leave (n = 2).
Equity impacts
Nine of the 50 (18%) eligible studies reported on the equity impact of the individual level economic relief programs (29, 32, 36, 41, 42, 45, 53, 58, 62). Program
types assessed included cash transfer (n = 2), incentive for vaccination (n = 3), mixed (n = 1), expanded paid sick leave (n = 1), and “other” (n = 2). The equity
factors considered were demographics (age, and race), socioeconomic status (employment), and jurisdiction.
Health outcomes associated with cash transfer programs differed across demographic factors (race and age) in two studies (58, 45). Cash transfer reduced
the incidence of COVID-19 symptoms among 50 years or older (45) and improved financial savings (a proxy for improved mental health) among Hispanics
(58).
In three studies assessing the effect of incentive for vaccination, health outcomes significantly differed by race, age, and employment (29, 42, 62). Vaccine
incentive increased vaccination rates among Blacks and non-working elderly in COVID-19 pandemic and influenza epidemic (29, 62). Vaccine incentive
reduced vaccine uptake among 40 years and older in a COVID-19 study (42).
Expanded child tax credit program reduced anxiety symptoms among Blacks and Hispanics (41). Domestic travel subsidy increased the incidence of COVID-
19 symptoms among young participants (53).
Table 1 presents the health, equity impact and non-health outcomes reported in eligible studies.
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Table 1
Summary of the health, non-health, and equity outcomes of individual level economic relief programs.
Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
Persaud Canada Randomized Cash transfer No difference No difference Self-reported Cash transfers Incidence of
2021 controlled in symptom health did not did not reduce COVID-19 like
trial in the number count after 2 differ between food insecurity symptoms
of close weeks (ratio of groups after 2 (80%vs 71%) reduced in
contacts means 0.83; weeks those aged
outside of the 95% CI 0.56 to 50 years or
household 1.24, p = 0.34) older, but not
between groups in those < 50
years (p =
(Rate ratio 1.10 0.005)
95% CI 0.83 to
1.46)
Tsai 2020 USA Survey Cash transfer NA NA Economic Economic NA
Impact Impact
Payment Payment was
recipients associated with
were more fewer problems
likely to have paying daily
tested positive expenses.
or been
untested for
COVID-19 and
less likely to
screen
positive for
current major
depression,
generalized
anxiety
disorder, past
2-week
suicidal
ideation,
COVID-19 era-
related stress,
and any illicit
drug use
compared to
those who did
not receive the
payment
Pichler USA Survey Expanded paid NA Relative to the NA NA NA
2020 (difference in sick leave mean number
difference of new cases
analysis) for the control
group, the
study model
predicted a
decrease of
417 new
COVID-19
cases (56%)
after the
introduction of
Families First
Coronavirus
Response Act.
Berkowitz USA Survey Unemployment NA NA Receiving The risk of food NA
2020 (difference in assistance unemployment insufficiency
difference insurance was lower for
analysis) benefits was those who
associated received
with lower risk unemployment
for unmet insurance
health-related compared to
social needs, those who did
and not. ( p <
depressive 0.0001)
and anxiety
symptoms.
Lee 2021 South Simulation Incentive for NA Study NA NA NA
Korea testing epidemiological
model
predicted an
increase in the
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Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
proportion of
confirmed
infected
patients out of
unidentified
infected people
in the
susceptible-
unidentified
infected-
confirmed
stimulated
population
Schneider USA Quasi- Expanded paid 15% reduction NA NA NA NA
2021 experimental sick leave in the
proportion of
workers who
reported
working while
sick
Ikeda 2021 Japan Survey Mixed NA NA the Special NA NA
Cash Payment
was
associated
with better
health related
quality of life
(95% CI): 0.05
(0.03 to 0.08)
Messer USA Survey Incentive for Coupled Program could NA NA Moderate
2021 vaccination incentives bring the US incentive
increase vaccination ($1500)
estimated levels from 58% increased
vaccination to more than vaccine
rates by 7–8%. 65% — uptake
(P = 0.03) substantially among Black
closer to the respondents
rates needed to to 68 per cent
reach herd (± 16%).
immunity. Similar trend
was found for
Latino
respondents.
Low income
was
associated
with low
vaccine
uptake. The
middle-
income
groups
appeared
most
responsive to
the vaccine
incentive.
Miyawaki Japan Survey Domestic Program Program NA NA Higher
2021 travel subsidy participants participants incidence
were more likely exhibited rates of
than non- higher COVID-19 like
participants to incidence of symptoms
engage in risky high fever were more
behaviour (adjusted OR: salient
(visiting 1.83; 95% CI among young
restaurants, 1.34 to 2.48), program
bars/nightclubs, sore throat participants
at least once); (aOR 2.09; 95% compared to
no impact on CI 1.37 to 3.19), non-
masking cough (aOR participants
practice, 1.96; 95% CI
respiratory 1.26 to 3.01),
hygiene headache (aOR
practice & 1.24; 95% CI
surface 1.08 to 1.44)
disinfection. and smell and
taste disorder
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Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
aOR 1.98; 95%
CI 1.15 to 3.40)
compared with
non-
participants.
Fan 2020 USA Survey Mixed The NA Unemployed
unemployed working-age
working-age population
population with
receiving government
government assistance
assistance residing in
had a higher urban areas
frequency of showed
feeling significantly
nervous, higher
lonely, and frequency
hopeless feeling
compared to nervous,
those without lonely, and
assistance hopeless
compared to
their non-
urban
counterparts
Acharya USA Survey Incentive for lottery NA NA NA NA
2021 vaccination programs were
associated with
an increase of
an average
23.12%
increment in the
new daily
vaccination
rate.
Algara USA Retrospective Incentive for positively NA NA NA NA
2023 observational vaccination influence
vaccine
preferences
among the
mass public
and all partisan
groups
Andersen USA Survey Expanded paid reduced the Weekly COVID- NA NA NA
2022 sick leave number of 19 incidence
hours people decreased by
were not at 7.7 log points.
home by a 0.38
h or 22.9-min
and the
proportion of
individuals
away from
home for more
than eight
hours per day
declined by
1.8% point.
Barr 2021 USA Survey Food NA NA The NA NA
assistance community-
based free
meal
distribution
program led to
healthier
eating and
reduced stress
among
participants
Batra 2023 USA Quasi- Expanded NA NA Program NA Adults of
experimental child tax credit resulted in Black,
fewer Hispanic, and
depressive other racial
and anxiety and ethnic
symptoms backgrounds
among low- demonstrated
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Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
income adults. greater
(13.3 percent reductions in
reduction from anxiety
baseline symptoms
anxiety levels compared to
(25.5 percent) non-Hispanic
White adults
with children.
Jacobson USA Randomized Incentive for Increases NA NA NA Financial
2022 controlled vaccination vaccination incentives
trial rates between reduced
1.0% and 1.6% vaccination
points. rates in both
older
individuals
(ages 40 and
over) and
those who
indicated they
supported
Trump in the
2020
presidential
election.
Jun'd 2022 Australia Survey Incentive for Program NA NA NA NA
vaccination participants
were 2.27 (95%
CI 1.73 to 2.99)
times more
likely to be
vaccinated.
Kim 2021 USA Survey Food NA NA Implementing NA NA
assistance SNAP subsidy
after
unemployment
insurance
expiration was
predicted to
lead to a 3-fold
higher risk of
anxiety and
depressive
symptoms
among those
experiencing
considerable
financial
hardship
versus no
hardship (P
< .001),
Liu 2023 USA Survey Cash transfer NA NA There was a NA African
negative American
association households
between the were less
amount of likely to
stimulus increase
received and spending,
financial Hispanic
hardship (a households
proxy for were more
mental well- likely to
being) increase
experienced savings.
by
respondents
during the
COVID-19
pandemic.
Pollack USA Longitudinal Expanded paid States with pre- NA NA NA NA
2022 observational sick leave existing paid
sick leave
policies
exhibited a
greater drop in
mobility (P <
001).
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Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
Shmueli Israel Survey Incentive for Program did not NA Incentives NA NA
2022 vaccination increase the such as
probability of monetary
getting rewards or the
vaccination green pass did
immediately. not
increase the
probability of
getting
vaccination
immediately.
Dudley USA Survey Incentive for the odds of NA NA NA NA
2021 vaccination reporting
receiving
influenza
vaccine
compared to
the control
group was 0.22
(95%CI: 0.09–
0.51)
Yue 2021 Singapore Randomized Incentive for increased NA NA NA The effect of
controlled vaccination participation in increasing
trial vaccination incentives on
from 4.5–7.5% influenza
(P = 0.001). vaccination
rates was
significant in
nonworking
elderly group
than those
who
worked(P = <
0.001) and
differed by
ethnicity (P =
0.001), socio-
economic
status(P = <
0.0001),
household
size (0.009),
and a
measure of
social
resilience (P
< 0.001)
Zhai 2018 USA Survey Expanded paid Compared to NA Paid sick leave NA NA
sick leave workers with no was
paid sick leave, independently
influenza associated
vaccination with seeking
coverage treatment for
estimates for influenza
workers with illness
paid sick leave (adjusted
was prevalence
approximately ratio (95%CI)
10–15% higher 1.21 (1.01,
1.44)
Asfaw USA Survey Expanded paid workers with Assuming 10– NA Paid sick leave NA
2018 sick leave paid sick leave 12% of days could save
spent an absent due to employers
average of 1.10 illness, 0.026% $0.63 to
more days away transmission $1.88 billion in
from work per rate, and an reduced illness-
year due to average daily related
illness or injury contact of three absenteeism
(95% CI: 0.90 to to five costs per year
1.30)] coworkers, a
worker at work
due to lack of
paid sick leave
could infect on
the average
0.0405 to
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Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
0.0810
coworkers per
year.
Wilson USA Survey Expanded paid Adjusted odds Decreased the Universal paid Universal paid White non-
2014 sick leave of having a number of leave is leave averted Hispanics
vaccination influenza cases predicted to 63.8 thousand had higher
increased with by 57 thousand result in 18.2 workdays lost odds of
paid leave vs. thousand to influenza receiving flu
without paid fewer each year, vaccination
leave (OR = healthcare than another
1.42, CI: 1.31– visits, for the race/ethnicity
1.53) flu annually.
Marinescu USA Survey Unemployment NA NA NA 10% increase in NA
2021 assistance unemployment
benefits
resulted in 3.6%
decline in job
applications
Kim 2020 South Survey Cash transfer NA NA NA Cash voucher NA
Korea scheme
increased
consumption
spending
among 36% of
the households.
Bienvenido- Spain Simulation Mixed NA NA NA Unemployment NA
Huertas aids could
2021 contribute to
alleviating
energy poverty,
especially if the
unemployed
individual
worked in a
poorly paying
job or for just a
few hours.
Han 2020 USA Simulation Cash transfer NA NA NA Government NA
cash program
resulted in a
decline in
poverty during
the COVID-19
pandemic.
Karger USA Simulation Cash transfer NA NA NA $1,200 stimulus NA
2021 payment
disbursed
increased
consumer
spending by
$546.
Fang 2020 USA Simulation Unemployment NA NA NA The CARES NA
assistance Unemployment
Insurance
policies
reduced
cumulative
deaths by 4.9%.
Evangelist USA Survey Unemployment NA NA NA the NA
2022 assistance unemployment
insurance
declined health
care services
spending
declined by 1%
Stiemele USA Survey Food NA NA NA Food insecurity NA
2021 assistance decreased
most among
those who
received the
local food
Page 11/20
Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
assistance
program
Raifman USA Retrospective Unemployment NA NA NA unemployment NA
2021 observational assistance insurance was
associated with
a 4.3%
decrease in
food insecurity
and a 5.7%
decrease in
eating less due
to financial
constraints.
Kubota Japan Survey Cash transfer NA NA NA Cash payments NA
2021 increased was
associated with
a jump in
spending rate
Fiang 2020 USA Survey Food NA NA NA The alternative NA
assistance school meals
improved with
food security
for lower-
income
families.
Martin USA Simulation Mixed NA NA NA Social NA
2020 protection
programs
reduced the
increase in
poverty rates
Clay 2021 USA Survey Food NA NA NA Food NA
assistance assistance
programs were
associated with
a higher
likelihood of
experiencing
food insecurity
(OR: 2.59
(1.62,4.16).
Raifman USA Survey Unemployment NA NA NA unemployment NA
2020 assistance insurance was
associated with
a 4.4% decline
in food
insecurity, and
6.1% decline in
eating less due
to financial
constraints.
Bhutta, USA Survey Mixed NA NA NA The CARES Act NA
2020 improved
households’
financial
security.
Men 2021 Canada Survey Mixed NA NA NA The applicants NA
of Canada
Economic
Response
Benefit, regular
Employment
Insurance
benefits, and
other
Employment
Insurance
benefits had
2.53, 1.80, and
3.01 times
higher adjusted
odds of food
insecurity,
respectively,
Page 12/20
Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
than non-
applicants.
Madeira Chile Survey Mixed NA NA NA Income and NA
2021 expenses
support
program
represented
13.6% of the
average
households’
permanent
income of poor
families in April
2020
Breunig Australia Retrospective Cash transfer NA NA NA Program NA
2023 observational recipient had
46% of their
weekly pre-
COVID‐19
wages replaced
by the
transfers.
Choi 2022 South Survey Cash transfer NA NA NA The stimulus NA
Korea payments
increased local
consumption in
establishments
accepting the
Gyeonggi local
currency
relative to other
establishments.
Li 2022 USA Survey Food NA NA NA SNAP NA
assistance significantly
reduced food
insecurity by
24.5% among
households
who were
already food
insufficient
before the
pandemic and
by 11.9% for
households
with children.
Lowery USA Survey Food NA NA NA Healthy Helping NA
2022 assistance program was
associated with
a $26.95
increase in
monthly
spending on
fruit,
vegetables,
nuts, and
legumes and
other shifts in
the
composition of
food
purchases.
Park 2022 USA Survey Unemployment NA NA NA Unemployment NA
assistance insurance
reduced
mortgage debt
payments.
Pilkauskas USA Randomized Cash transfer NA NA The cash The cash NA
2023 controlled transfer transfer
trial program had program had no
no impact on impact on
mental health material
hardship,
parenting, child
behavior,
Page 13/20
Author, Country Study Design Economic Public health Population General well- Non-health Equity impact
year relief program measure health being outcomes
type impact outcomes
associated with
public health
measure
impact
partner
relationships,
hardship
avoidance,
consumption,
employment,
and benefit use
Wahdat USA Survey Cash transfer NA NA NA Economic NA
2022 Impact
Payment was
associated with
9.2% decrease
in food
insufficiency.
Insert Table 1
Limitations associated with individual-level economic relief programs.
Three studies discussed the limitations of their respective programs (18, 27, 54). Limitations associated with unemployment assistance programs in two
studies included state-level variability in unemployment insurance benefits (18), the complexity of the unemployment insurance program structure, the
presence of barriers that prevent eligible individuals from receiving program benefits (18), and issues related to eligibility and implementation challenges,
such as erroneous data on unemployment rate (27). In a COVID-19 cash transfer program study, the authors suggested that the implemented consumption
voucher program could constrain consumer choice and possibly harm consumer welfare and economic efficiency in the long run because beneficiaries could
only redeem the vouchers at small business stores (54).
Knowledge gap
Our review identified four key knowledge gaps:
Limited disease focus. All eligible studies were on COVID-19 and influenza. Despite the occurrence of SARS, H1N1 influenza, MERS, Ebola, Zika and West Nile
Virus outbreaks during eligibility period, we did not identify any eligible study on these outbreaks in our review.
Lack of evidence on the effect of unemployment assistance programs and food assistance programs on public health measures (such as physical
distancing, quarantine/isolation, vaccination). Among the unemployment assistance programs and food assistance programs studies included in our review,
none reported on public health measure impact.
Limited evidence of the impact of individual-level economic relief programs on equity. Only 16% of eligible studies reported on the equity impact. None of the
eight studies that assessed the equity impact of unemployment assistance programs, vaccine incentive programs, “other” programs, and cash transfer
programs reported the program's effect on relevant equity variables. The impact of expanded paid sick leave programs and food assistance programs on
equity remains undetermined.
Lack of evidence on the long-term effect of individual-level economic relief programs on health outcomes, which were not considered in the 36 eligible
studies that reported health outcomes. Assessing the long-term health effects of individual-level economic relief policies, particularly post-pandemic during
the recovery stage, could provide insight into the importance of the programs to equity and societal well-being.
DISCUSSION
Our review charts the current state of the literature on the types of individual-level economic relief programs implemented during infectious disease
outbreaks. Overall, our review has four key findings.
First, our finding suggests a concentration of studies conducted in the USA. The predominance of studies in the USA is striking and may indicate protection
of its vulnerable population (70) from the “lockdown” effect in the context of historically lower investment on social protection programs pre-pandemic
compared to other G7 countries (71).
Second, expanded paid sick leave was found to have a consistent pattern of improved health outcomes. Our findings corroborate the findings of a recent
meta-analysis study of 12 studies, reporting that paid sick leave was associated with increased odds of following public health directives (vaccine uptake)
and seeking medical care (72).
Third, individual-level economic relief programs improved population health outcomes among equity-deserving populations. The improved health outcomes
observed among equity seeking populations is likely due to their improved adherence to public health measures enabled by economic relief programs. (73).
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Lastly, most individual-level economic relief program types positively impacted mental health, re-affirming the long-established evidence of the relationship
between financial well-being and psychological well-being (74, 75). Non-health outcomes associated with the programs had beneficial impact on key
domains of social determinants of health i.e., economic stability and healthcare access and quality. Addressing social determinants of health is fundamental
for improving health and reducing longstanding inequities in societal health (76).
Our review has some limitations. First, we restricted our search strategy to studies in high-income countries due to the high volume of studies. Future reviews
should synthesize the impact of similar programs in low-and middle-income countries. Second, due to the volume of studies identified we were only able to
focus on selected infectious diseases. This limitation makes our findings disease-specific, requiring careful interpretation if attempting to extrapolate
findings to other infectious diseases (e.g., HIV). Further, we did not search the grey literature and only included publications in English. Our findings may
therefore be biased towards English-speaking high-income settings.
Our review’s strength lies in our use of a rigorous scoping review methodology. Screening and data extraction forms were pretested by all reviewers and
revised as needed to ensure they are adequately sensitive to capture outcomes in eligible studies. We searched multiple relevant electronic scientific
databases to ensure our results were comprehensive and accurate. Lastly, our eligibility criteria had no restriction on study design.
Our findings provide compelling evidence that individual-level economic relief programs provide broad and positive impact on public health measures,
population health, general well-being, equity, and social determinants of health (e.g., economic stability).
As countries prepare for future pandemics, our findings provide evidence to stakeholders to recognize health equity as a fundamental public health goal
when designing pandemic preparedness policies.
CONCLUSION
Individual-level economic relief programs implemented during epidemics/pandemics significantly impacted public health measures, outbreak-related
population health outcomes and health equity. Our findings can inform investments in individual-level economic relief programs to protect population health
in future pandemics, particularly for equity-seeking populations, to prevent the widening of pre-existing societal inequity.
Declarations
Ethics approval and consent to participate: Not applicable.
Consent for publication: Not applicable
Availability of data and materials: All data generated or analysed during this study are included in this published article and its supplementary information
files.
Competing interests: The authors declare that they have no competing interests.
Funding: The preparation of the manuscript was supported by Emerging and Pandemic Infections Consortium, University of Toronto
Authors' contributions: AO and BS conceptualized the study. AF acquired the data. AO, GBG, AP and MH screened and analyzed the data. AO, KL, SM, BS
interpreted the data. AO drafted the manuscript. AF, SM, KL and BS revised the manuscript. All authors read and approved the final manuscript.
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Figures
Figure 1
Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) flowchart
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Figure 2
Heat map depicting program and studies characteristics of included studies
Footnotes: [The number of studies by individual-level economic relief program type and country are ordered from highest to lowest (left to right). We
assigned dark to light colours to depict a no study scenario to having more than 6 studies scenarios].
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Figure 3
Coxcomb Chart depicting study outcomes by individual-level economic relief program type
Footnotes: [The different colours of the ray indicate the various components of the review outcomes. The width of the ray indicates the impact of the
individual-level economic relief program type on the components of the review outcomes. A wide width implies that the individual-level economic relief
program type has a positive impact on the specific review outcome assessed and a narrow width denotes a negative impact.]
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